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TPE Results

January – March 2026

Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education to providers during, and upon completion of, each round of review.

The information below describes Targeted Probe and Educate (TPE) results for home health and hospice (HHH) providers.

Home Health Probes Completed

Current Edits

The primary focus of these reviews is to determine if the medical record documentation supports Medicare guidelines for medical necessity of the services billed. Current home health edits for TPE include:

Review Topic	Edit Numbers	Description	Review Type
Medical necessity	5A007 5B007 5C007	This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2.	TPE prepayment review
New providers	5A006 5B006 5C006	This edit selects home health claims for relatively new providers who have submitted at least 50 claims.	TPE prepayment review
Medical necessity	5N000 5T000 5V000	This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2.	TPE Round 1 postpayment Round 2 prepayment Round 3 prepayment

Results

Results	5A007 Round 1	5B007 Round 2	5C007 Round 3	5A006 Round 1	5B006 Round 2	5C006 Round 3	5T000 Round 2	5V000 Round 3
Probes completed	12	14	5	4	2	1	1	4
Providers compliant after round completion	4	13	3	1	0	1	1	4
Providers non-compliant after round completion (advancing)	8	1	2	3	2	0	0	0
Providers with non-response to ADRs	0	1	0	1	0	0	0	0
Education contacts	14	30	9	17	5	0	0	6

Findings by State

Summary of findings for providers that completed rounds of review (by state):

Findings summary

Top Denial Reasons

See Home Health Medical Review Denials for details and resources to help avoid future claim denials.

Rank	Reason Code	Description	% of TPE Denials
1	5HN18	Skilled nursing not medically necessary	26.5%
2	5HC01	Face-to-face documentation missing, incomplete, or untimely	24.1%
3	5HC09	Initial certification invalid	13.4%
4	5HY01	Therapy visits not medically necessary	9.6%
5	5HC05	No Plan of Care/certification	6.2%

Hospice Probes Completed

Current Edits

The primary focus of these reviews is to determine if medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current hospice edits for TPE include:

Review Topic	Edit Numbers	Description	Review Type
LOS with non-oncologic diagnosis	5D000 5E000 5F000	This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code.	TPE prepayment review
GIP LOC	5D006 5E006 5F006	This edit selects hospice providers who submitted claims with revenue code 0656 greater than or equal to 7 days.	TPE prepayment review
New providers	5D008 5E008 5F008	This edit selects hospice claims for relatively new providers who have submitted at least 50 claims.	TPE prepayment review
LOS 313-515 days	5D010 5E010 5F010	This edit selects hospice providers who submitted claims with length of stay (LOS) 313-515 days.	TPE prepayment review

Results

Results	5D000 Round 1	5E000 Round 1	5E006 Round 1	5D008 Round 1	5E008 Round 1	5F008 Round 3	5D010 Round 1	5E010 Round 2	5F010 Round 3
Probes completed	1	1	1	22	1	3	9	3	2
Providers compliant after round completion	0	1	1	15	1	2	4	1	1
Providers non-compliant after round completion (advancing)	1	0	0	7	0	1	5	2	1
Providers with non-response to ADRs	0	0	0	2	0	0	1	0	0
Education contacts	1	0	0	51	9	9	14	8	0

Findings by State

Summary of findings for providers that completed rounds or review (by state):

Findings summary

Top Denial Reasons

See Hospice Medical Review Denials for details and resources to help avoid future claim denials.

Rank	Reason Code	Description	% of TPE Denials
1	5PM01	Terminal prognosis not supported	54.2%
2	5PX06	Notice of Election (NOE) invalid	21.7%
3	5PC01	Physician certification of terminal illness missing or invalid	8.9%
4	5PC02	Physician certification of terminal illness missing	3%
5	5PC03	Initial start of care physician certification of terminal illness invalid	2.7%

Education

Education sessions are available via webinar, teleconference, or other methods:

CGS offers an individualized education session to providers with a moderate to high error rate. This includes the opportunity to discuss each claim found in error and address any questions or concerns.
Any provider may also request an individualized education session at any time.
Widespread education sessions are posted on the HHH Calendar of Events.

Please email questions or education requests to: J15HHPROBEANDEDUCATION@CGSADMIN.COM.

Next Steps

At the completion of TPE round 1/2, providers identified as non-compliant will advance to TPE round 2/3 at least 45 days from the 1:1 post-probe education call completion date. You may request education at any time even if you aren't elected for TPE. CGS encourages providers to request education, conduct self-monitoring based on our Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) available in the myCGS portal.

References

Updated: 05.20.2026

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

TPE Results

January – March 2026

Home Health Probes Completed

Current Edits

Results

Findings by State

Top Denial Reasons

Hospice Probes Completed

Current Edits

Results

Findings by State

Top Denial Reasons

Education

Next Steps

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